Rehabilitation: Femoral Condyle MACI repair

Rehabilitation Guide for Femoral Condyle MACI Repair

First 6 weeks: Graft Protection phase

First 1 -2 days before going home

KNEE EXTENSION SPLINT (BRACE) APPLIED IN THEATRE HOLDING KNEE STRAIGHT until first morning. Then start bending knee on first morning. Leg to stay straight in knee brace when walking and at night for 2 weeks until fully comfortable with mobility.

Principle: This phase must allow protection of the graft from the shear forces associated with moving the knee under load. Movement without load is vital to aid nutrition of the joint surfaces. Wt bearing is gradually increased to 80% of full wt bearing at 6 weeks, and full wt bearing at 8 weeks.

Brace: Locked in extension when walking for first 2 weeks then unlocked. Can be removed between 2 and 4 weeks when comfortable straight leg raise and adequate quads control

Weight bearing: Initially touch weight bearing until 2 weeks then progressive increase weekly to 80% of full weight bearing at 6 weeks and full weight bearing at 8 weeks

Weeks 7-12 Transition and Loading phaseDuring this phase the aim is to regain full flexion and start strength work without bringing on swelling or putting shear forces on the graft. The swelling determines progress of exercises. Ice after exercise may help.

The brace is removed and normal walking is allowed BUT no excessive load on the patella-femoral surfaces until 3 months

Wt bearing: Full weight bearing without crutches

Range of movement: Build to full flexion and maintain full extension

Strength exercises: closed chain strength work introducing open chain not before 12 week

Functional activities: Driving – when safe bend and control at around 8 weeks

Month 4 - 6 Maturation phaseIncreasing strength work and starting functional exercises without bringing on swelling. The graft can begin to tolerate some shear forces from open chain exercises.

During this phase increased load on the articulating surfaces is allowed but the intention remains to keep load off the patella-femoral surfaces for as long as possible.

Therefore the sequence is a gradual increase in functional training with the mainstay being cycling with gradually increasing load.

Wall slides are to be avoided

Activities that increase swelling are to be avoided

Treadmill fast walk – supervised only

Stepper / Cross trainer

↑ Walking distance

Circuit training

No progression to jogging until 6 months

Cycling, rowing and cross-trainer but no jumping.

Continue strength training as effusion resolves

6 Months Onwards: Return to functional activitiesThe graft is now firm – but not fully mature. There may still be some sensation of grating and again swelling is used as the guide to progress. Avoid generating swelling and pain. Gradual progression and aim to begin sports specific training when agreed with consultant/ physiotherapist.

Gentle jog, then gentle change of direction single leg hurdle/step over under supervision.

Acceleration/Deceleration up to 50% speed.

Plyometrics.

Skipping and hopping.

Star jumps (from 8 months).

Acceleration/Deceleration runs ¾ speed (from 8 months).

Figure of 8 runs forwards/backwards.

Slalom forwards/ backwards.

Run–sit–run then gradually introduce cutting/sudden stop.

Increasing running distance and progress to sprints 10m-20m-50m.

After 12 months an MRI scan or second look arthroscopy may be performed. If the grafted area is looking good with filling in of the damaged area and good bonding with the surrounding articular cartilage then return to contact sports is allowed.

Exercises are then tailored to the sport and regaining the required skills and endurance. In addition confidence building and retraining to avoid re-injury is required

Not everyone goes back to their previous level of sport and many choose to conserve the newly repaired knee, knowing that the real goal is a long lasting knee.